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Commissioning for Effective Smoking Cessation Delivery North East Smoking Cessation Conference


1. Locally Lead the NHS ... Doesn't direct but allows providers to respond and instead focuses on the outcomes' sought ... Develop and deliver local NHS SSS ... – PowerPoint PPT presentation

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Title: Commissioning for Effective Smoking Cessation Delivery North East Smoking Cessation Conference

Commissioning for Effective Smoking Cessation
Delivery North East Smoking Cessation
  • Martyn Willmore Performance Improvement
    Delivery Manager, Fresh
  • Sarah Edwards Associate Delivery Manager

To be covered today...
  • World Class Commissioning and the eleven
    competencies for stopping smoking
  • Summary of Commissioning Tools and Levers
  • An introduction to the Integrated Service
    Framework for Stop Smoking Services
  • Targeting Routine and Manual Occupational Group
  • Recommendations for commissioners and providers
  • Discussion

WCC for Smoking linking the 11 Competencies
  • 1. Locally Lead the NHS
  • Vision, Strategy and whole system leadership role
    of the PCT and its responsibility to give clear
    signals to health care providers about its
    intentions including primary, community,
    secondary and tertiary and their links to social
    care, and local government well-being issues
    where relevant
  • 2. Work with Community Partners
  • - Do the priorities expressed in the JSNA, LAA
    and CSP make solid links to tobacco control and
    smoking cessation, so that the case for change is
    shared collaboratively between LAs, PCTs, Acute
    Trusts and 3rd Sector strengthening the
    business case and local agenda? Strategy
    reflects the range of partners existing and
  • 3. Engage with public and the patients
  • - Can the Stop Smoking Services demonstrate the
    values that patients and the public hold? Have
    patient and public views, satisfaction and
    outcomes been tested through reputable and
    reliable methods?

WCC for Smoking linking the 11 competencies
  • 4. Collaborate with clinicians
  • Use of evidence base for smoking cessation in a
    way that promotes acceptance and ownership
    amongst clinicians.
  • Evidence grading in the Service Monitoring
    Guidance 2009
  • 5. Manage knowledge and assess needs
  • Needs assessment through referenced,
    authoritative sources of data and intelligence.
  • eg. disease Incidence, prevalence, health
  • Sufficient context taking account of ethnicity,
    age, demographic structure
  • Use of intelligence/data to help identify and
    de-commission ineffective interventions,
    (hypnotherapy, smoke free homes)
  • Use of the data and intelligence to engage
    community partners ie. 3rd Sector/Social Care
    interventions. Carers high prevalence of
  • 6. Prioritise investment
  • - Clarifies the outcomes and gains to enable view
    of short, medium and long term benefits.
    (Prevention not a priority treating adults)

WCC for Stopping Smoking linking the 11
  • 7. Stimulate the Market
  • Assess and monitor the state of the market to
    respond to commissioning signals and intentions.
    (pre-qualification activity, marketing testing)
  • Doesnt direct but allows providers to respond
    and instead focuses on the outcomes sought
  • 8. Promote Improvement and Innovation
  • Uses tested and credible measures that can be
    used to monitor quality and improvement including
    in this the requirements they make of providers.
  • Distinguishes between service models and
    technologies that can result in performance
    improvement and those which are truly innovative
  • 9. Secure Procurement Skills
  • Signpost providers to measures, accreditation
    systems and other quality hallmarks that can be
    used in service specs and invitations to tender
    (avoiding any assumptions about the provider).
    Gold standard monitoring guidance, NICE guidance.
  • Balance and focus on evidence of outcomes and
    process measures, in such a way that will inform
    appropriate contract length. eg.12 months, 3

WCC for Stopping Smoking linking the 11
  • 10. Manage the local health system
  • Uses evidenced based information to inform the
    scale and scope of care of service, clinical
    outcome and patient safety SO THAT...
  • the best service model or configuration delivers
    acceptable outcomes for the community.
  • 11. Make Sound Financial Investments
  • - uses clear and comparative benchmarking
    information, to assist in obtaining value for
  • - Financial costing is modelled taking
    into account fixed and variable
  • costs as the service increases or
    decreases. Eg. costs per quitter.

Commissioning Tools and Levers
  • Contracts and Service Level Agreements
  • content of service specifications, duration,
  • Local Enhanced Services (LESs) incentives
  • Care Pathways and Pathway redesign
  • Practice Based Commissioning
  • Quality and Outcomes Framework (QOF)
  • Social Marketing
  • Partnerships
  • 3rd Sector - Section 31. TSIP third sector
    investment programme

(No Transcript)
Integrated Service Framework- ISF
  • Evolved over the past 12 months pragmatic
  • framework that allows smokers to be
  • Identified (opportunistically) - in appropriate
  • Offered a menu of stop smoking support
  • Signposted/referred to the support of choice
  • Co-ordinated by a central core function
  • Sits in line with current NHS Stop Smoking
  • Service and Monitoring Guidance 09/10
  • Has 4 elements
  • core team, settings, level of support and routine
    and manual

1. Core Team
  • Core Team refers to a team comprising of
    service manager, specialist advisors and support
    staff commissioned by the PCT.
  • Key objectives are
  • Develop and deliver local NHS SSS
  • Co-ordinate the network of support in the 6 key
    settings (develop and streamline care pathways)
  • Provide specialist support for smokers in high
    risk groups (RM, Pregnant smokers, BME)
  • Work in partnership with PH intelligence to
    assess needs and wants of local smokers
  • Ensure consistent effective support service
    user evaluation, adhering and advising on
    evidence base

2. Settings
  • Primary care GP practices, dentistry
  • Pharmacy
  • Community Settings (working with the third
  • Maternity and Family Services
  • Secondary Care
  • Mental health
  • NB
  • Every setting provides opportunities to engage
    with smokers, utilising the skills of
    professionals and including access to stop
    smoking medicines
  • Every settings provides commissioners with
    opportunities to develop service pathways
    underpinned by local enhanced service contracts,
    service level agreements etc

3. Level of support
  • Level of support provided is determined by the
    setting and contractual agreement
  • All levels can be delivered in each setting as
    long as advisors are trained, resourced and
    supported by a core team
  • Very brief 30 second approach ASK, ADVICE and
  • Brief 5 to 10 minutes of advice and referral
  • Intensive min of 1.5 hours of structured
    support including access to SS meds over a period
    of 4-weeks

4. Routine and Manual
  • 2 Public Service Agreements (PSA) relating to
    smoking prevalence
  • - To reduce prevalence among the general
    population to
  • 21 or less by 2010
  • - To reduce smoking prevalence in routine (RM)
  • manual groups to 26 or less by 2010
  • In addition there is a health inequality PSA
  • - To reduce inequalities in health outcomes by
    10 as measured by infant mortality and life
    expectancy at birth
  • - Starting with children under 1 year, by 2010
    to reduce by at least 10 the gap in mortality
    between RM groups and the population as a whole
  • - Starting with local authorities, by 2010 to
    reduce by at least 10 the gap between the fifth
    of areas with the lowest life expectancy at
    birth and the population as a whole

Routine and manual (2)
  • Smoking remains the leading cause of preventable
    death and illness in England
  • Smokers are often concentrated in poorer
    communities and are represented in each of the
    settings highlighted in the ISF
  • Smoking is a major contributor of infant
    mortality (IM) i.e.
  • Smoking in pregnancy increases IM by approx 40
  • Smoking prevalence is 1.5 times higher in RM
    pregnant women than the population as a whole
  • As smoking is responsible for one-sixth of all
    deaths in the UK it is the area where behaviour
    change would make the greatest impact on health
  • Supporting smokers to quit impacts positively on
    the PSA smoking prevalence and health inequality
    targets including infant mortality

Rationale for supporting RM smokers to quit
  • Greatest volume of smokers is to be found in the
    RM group, therefore
  • This is where the greatest volume of
    smoking-related health inequalities are found
  • The greatest gain if they can be effectively
    supported to quit
  • RM are not hard to reach (they will engage
    with services but they do find it harder to stay
  • There is a clear evidence base, backed by
    national media campaigns, on how to engage and
    support RM smokers
  • Not yet available for other harder to reach
    niche groups where numbers of smokers may be
  • Because a third of RM smokers live in the most
    deprived 20 of areas, reducing rates in this
    group will help de-normalise smoking in these
    areas, making it easier for niche groups to
    quit when the evidence is available

Defining RM
  • In 2007 there was an estimated 15 million people
    in the RM group
  • 26 smoke 28 men and 24 women
  • They account for approx 50 of smokers in England
    or 4.25 million smokers
  • RM smokers are defined by their occupation
  • RM smokers defined by occupational, but most
    non-employed persons (the unemployed, the
    retired, those looking after a home, those on
    government employment or training schemes, the
    sick and people with disabilities etc) are
    classified according to their last main job so
    can be included.
  • Exceptions are full-time students, those who have
    never worked or are long-term unemployed.

Defining RM continued..
  • The RM group
  • Have a higher aged 25 to 45 years compared with
    general population
  • Are more likely to have children aged 0 to 5
  • Are more likely to live in North of England,
    North West, North East and Midlands than South of
  • Are likely to live in the most deprived 20 of
    areas approx a third and out of these 37 smoke
  • In terms of smoking
  • More likely to have started young (16 years or
  • More likely to be heavily addicted (defined as
    having first cigarette within 5 minutes of waking

Marketing insights into RM smokers
  • RM workers tend to establish standard routines
    in which smoking is entrenched
  • Family and community are very important many
    live in close proximity and socialise together.
    Quitting is therefore isolating and often leads
    to relapse
  • Quitting is daunting - RM smokers know from
    experience that quitting is hard and likely to
    end in failure. The short-term benefits are
    minimal when compared to the pain and the fact
    that the longer term benefits will not be felt
    for some time
  • Smoking is integral to who they are, it is not
    just something RM smokers do. Becoming a non or
    even an ex-smoker is out of character
  • Smoking fulfils many needs
  • a fix - helps relax
  • a coping mechanism - a reward

Maximising opportunities to target RM through
wider tobacco control
  • Stop smoking services (SSS) should not operate in
    isolation as this will not maximise their
    potential reach and efforts into RM communities
  • SSS is only 1 strand of 7 that ensure a
    comprehensive approach to tobacco control
  • 3 core strategic elements
  • Planning and commissioning
  • Developing multi-agency partnership working
  • Monitoring, evaluation and response
  • 4 operational work streams
  • Making it easier to stop smoking
  • Tackling cheap and illicit tobacco
  • Normalising smoke-free lifestyles
  • Communication
  • Each work stream feeds into and includes the core
    elements. This ensures activities are

  • PCT Commissioners
  • Consider joint commissioning with LAs the PSA
    targets are jointly owned and the 7 strands
    includes activities that are health and local
    authority based
  • Deploy World Class Commissioning criteria and
    start with SSS as it provides a useful starting
    point then move onto wider tobacco control
  • Ensure service level agreements are underpinned
    by evidence and local needs assessment in terms
    of RM this includes
  • DH Tobacco Control Marketing and Communications
    Strategy (2008 -2010)
  • The NHS SSS and Monitoring Guidance (2009)
  • The 10 High Impact Changes for local Tobacco
    Control (2007)

Other considerations
  • PCT Commissioners Reach vs quality
  • Services that increase access, particularly for
    target groups
  • out of hours,
  • convenient accessible locations,
  • stimulate demand
  • range of options for support
  • work within a range of settings
  • Services that offer high quality (see DH
  • most successful behavioural support (groups) as
    well as variety of ways
  • most successful meds offered first line
    (varenicline combo NRT) as well as the full
    range of products
  • Gold standard data monitoring, CO validation,
    client satisfaction, quit rate approx 50,
    other service indicators
  • Services that are integrated systematised
    across health social care, no matter what
    organisation is delivering different aspects (see

  • PCT Providers
  • Provide SS support to RM smokers through an
    Integrated Service Framework model
  • Utilise national branding linking local
    targeted stop smoking support to national RM
  • Implement national marketing strategy programmes
    as and when they become live i.e.
  • Implement the healthcare professionals programme
    (formerly SCIP)
  • Work in partnership with face2face field
  • Raise awareness of local SSS through national
    campaigns (NSD)
  • Link with the RTPM and delivery team
  • Gather local RM intelligence feed back to
    commissioners to inform future service
  • Support wider tobacco control work streams
  • - i.e. Gather and share other tobacco related
    intelligence availability of cheap and illicit
    tobacco and feedback to strategic partners
    (trading standards) .

  • Third Sector
  • National Marketing Strategy advocates community
    activation as a way of generating quit attempts
    in RM smokers
  • Voluntary and community organisations are well
    placed as influencers in local communities
  • Community is important to RM smokers third
    sector organisations can
  • Provide local intelligence and insights to
    compliment national insights
  • Provide local support
  • Signpost smokers to specialist core SSS

Implications for commissioners and providers -
Where do you start?
  • Depends on what is already in place and how
    effective it is
  • If there is no core team makes sense for
    commissioners to start there/providers to develop
    a core function that for purpose
  • If core team is already in place commissioners
    could begin with primary care and pharmacy
    moving through the settings, as each element is
    developed with clear care pathways and
    underpinned through contractual processes

Questions Discussion